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					                                                    Montana Medicaid
                                              Nursing Facility Code Crosswalk



                                                        CURRENT    PREVIOUS                           MEDICARE Prior
Category of Service        CURRENT ITEM                                            PREVIOUS
                                                       PROCEDURE   CODE OR                              EOB    Auth.
     Section #              DESCRIPTION                                           DESCRIPTION
                                                          CODE      CODES                              NEEDED Required
                                                                                Colostomy set,
                                                                                Ureterostomy set
Ostomy Supplies       Surgical Tray                      A4550     A4360, A4430                            Y          No
                                                                                (or A4310-A4316),
                                                                                Ileostomy set
Ostomy Supplies       Ostomy faceplate, each             A4361        A4361     Ostomy faceplate           Y          No
                      Ostomy faceplate
Ostomy Supplies       equivalent, silicone ring,         A4384        A4361     Ostomy faceplate           Y          No
                      each
                      Ostomy skin barrier, with
                      flange (solid, flexible or
Ostomy Supplies                                          A4373        A4362     Ostomy skin barrier        y          No
                      accordion), with built-in
                      convexity, any size, each
                      Ostomy skin barrier, pectin-
Ostomy Supplies                                          A4406        A4362     Ostomy skin barrier        y          No
                      based, paste, per ounce

                      Ostomy skin barrier, with
                      flange (solid, flexible or
Ostomy Supplies       accordion), extended wear,         A4407        A4362     Ostomy skin barrier        y          No
                      with built-in convexity, 4x4
                      inches or smaller, each
                      Skin barrier; solid, four by
Ostomy Supplies                                          A4362        A4362     Ostomy skin barrier        Y          No
                      four or equivalent; each
                      Ostomy skin barrier, with
                      flange (solid, flexible or
                      accordion), extended wear,
Ostomy Supplies                                          A4410        A4362     Ostomy skin barrier        y          No
                      without built-in convexity,
                      larger than 4x4 inches,
                      each
                      Ostomy skin barrier, with
                      flange (solid, flexible or
                      accordion), extended wear,
Ostomy Supplies                                          A4408        A4362     Ostomy skin barrier        y          No
                      with built-in convexity,
                      larger than 4x4 inches,
                      each
                      Ostomy skin barrier, solid
Ostomy Supplies       4x4 or equivalent, with built-     A4372        A4362     Ostomy skin barrier        y          No
                      in convexity, each
                      Ostomy skin barrier, solid
                      4x4 or equivalent,
Ostomy Supplies                                          A4385        A4362     Ostomy skin barrier        y          No
                      extended wear, without
                      built-in convexity, each
                      Ostomy skin barrier, non-
Ostomy Supplies       pectin based, paste, per           A4405        A4362     Ostomy skin barrier        y          No
                      ounce
                      Ostomy skin barrier, solid
                      4x4 or equivalent,
Ostomy Supplies                                          A4385        A4362     Ostomy skin barrier        Y          No
                      extended wear, without
                      built-in convexity, each
                      Ostomy skin barrier,
Ostomy Supplies                                          A4371        A4362     Ostomy skin barrier        y          No
                      powder, per oz

                                                                                                   Effective March 1, 2004
                                                   Montana Medicaid
                                             Nursing Facility Code Crosswalk

                                                     CURRENT    PREVIOUS                             MEDICARE Prior
Category of Service        CURRENT ITEM                                           PREVIOUS
                                                    PROCEDURE   CODE OR                                EOB    Auth.
     Section #              DESCRIPTION                                          DESCRIPTION
                                                       CODE      CODES                                NEEDED Required
                      Ostomy skin barrier, with
                      flange (solid, flexible or
Ostomy Supplies       accordion), extended wear,      A4409       A4362        Ostomy skin barrier         y          No
                      without built-in convexity,
                      4x4 inches or smaller, each

                      Ostomy skin barrier, liquid                              Ostomy liquid
Ostomy Supplies                                       A4369       A4363                                    Y          No
                      (spray, brush, etc), per oz                              barrier
                      Adhesive, liquid, or equal,                              Ostomy skin bond
Ostomy Supplies                                       A4364       A4364                                    Y          No
                      any type, per ounce                                      or cement
                      Ostomy pouch, urinary, for
                                                                               Ostomy bag,
Ostomy Supplies       use on faceplate, plastic,      A4381       A4365                                    Y          No
                                                                               disposable/closed
                      each.
                      Ostomy pouch, closed;
                                                                               Ostomy bag,
Ostomy Supplies       with barrier attached (one      A5051       A4365                                    Y          No
                                                                               disposable/closed
                      piece), each
                      Ostomy pouch, urinary, for
                                                                               Ostomy bag,
Ostomy Supplies       use on faceplate, rubber,       A4383       A4365                                    Y          No
                                                                               disposable/closed
                      each.
                      Ostomy pouch, closed; for                                Ostomy bag,
Ostomy Supplies                                       A5053       A4365                                    y          No
                      use on faceplate, each                                   disposable/closed
                      Ostomy pouch, closed; for
                                                                               Ostomy bag,
Ostomy Supplies       use on barrier with flange      A5054       A4365                                    Y          No
                                                                               disposable/closed
                      (two piece), each
                      Ostomy pouch, closed,
                      with barrier attached, with                              Ostomy bag,
Ostomy Supplies                                       A4387       A4365                                    Y          No
                      built-in convexity (one                                  disposable/closed
                      piece), each
                      Ostomy pouch, urinary,
                                                                               Ostomy bag,
Ostomy Supplies       with faceplate attached,        A4379       A4365                                    Y          No
                                                                               disposable/closed
                      plastic, each.
                                                                               Ostomy bag,
                                                                               disposable/closed -
                                                                               Use most
                                                                               appropriate
                      Adhesive remover wipes,                                  HCPCS Level II
Ostomy Supplies                                       A4365       A4365                                               No
                      any type, per 50                                         Code - possible
                                                                               codes
                                                                               A4387 or A4379-
                                                                               A4383 or A5051-
                                                                               A5054
                      Ostomy pouch, closed;
                                                                               Ostomy bag,
Ostomy Supplies       without barrier attached        A5052       A4365                                    y          No
                                                                               disposable/closed
                      (one piece), each
                      Ostomy pouch, drainable,                                 Ostomy bag,
Ostomy Supplies       with faceplate attached,        A4375       A4366        reusable or                 Y          No
                      plastic, each.                                           drainable
                      ostomy pouch , urinary,
                                                                               Ostomy bag,
                      with extended wear barrier
Ostomy Supplies                                       A4393       A4366        reusable or                 Y          No
                      attached, with built-in
                                                                               drainable
                      convexity (1 piece), each
                      Ostomy pouch, urinary,
                                                                               Ostomy bag,
                      with standard wear barrier
Ostomy Supplies                                       A4392       A4366        reusable or                 Y          No
                      attached, with built-in
                                                                               drainable
                      convexity (1 piece), each                                                    Effective March 1, 2004
                                                       Montana Medicaid
                                                 Nursing Facility Code Crosswalk

                                                      CURRENT       PREVIOUS                              MEDICARE Prior
Category of Service        CURRENT ITEM                                               PREVIOUS
                                                     PROCEDURE      CODE OR                                 EOB    Auth.
     Section #              DESCRIPTION                                              DESCRIPTION
                                                        CODE         CODES                                 NEEDED Required
                      Ostomy pouch, urinary,                                       Ostomy bag,
Ostomy Supplies       with extended wear barrier         A4391        A4366        reusable or                Y           No
                      attached (1 piece), each                                     drainable
                      Ostomy pouch, drainable,                                     Ostomy bag,
Ostomy Supplies       with faceplate attached,           A4376        A4366        reusable or                Y           No
                      rubber, each.                                                drainable
                      Ostomy pouch, drainable,
                                                                                   Ostomy bag,
                      with barrier attached, with
Ostomy Supplies                                          A4389        A4366        reusable or                Y           No
                      built-in convexity (one
                                                                                   drainable
                      piece), each

                      Ostomy pouch, drainable,                                     Ostomy bag,
Ostomy Supplies       with extended wear barrier         A4388        A4366        reusable or                Y           No
                      attached, (one piece), each                                  drainable
                      Ostomy pouch, drainable,                                     Ostomy bag,
Ostomy Supplies       for use on faceplate,              A4377        A4366        reusable or                Y           No
                      plastic, each.                                               drainable
                      Ostomy pouch drainable,                                      Ostomy bag,
Ostomy Supplies       for use on faceplate,              A4378        A4366        reusable or                Y           No
                      rubber, each.                                                drainable
Ostomy Supplies       Ostomy belt, each                  A4367        A4367        Ostomy belt                Y           No
                                                                                   Stoma wicks- No
                                                                                   code for this item.
                      Ostomy filter, any type,
Ostomy Supplies                                          A4368        A4368        Code # previously          Y           No
                      each
                                                                                   used is now
                                                                                   Ostomy Filter.

                                                                                   Tail closures- No
                                                                                   code for this item.
                      Ostomy skin barrier, liquid
Ostomy Supplies                                          A4369        A4369        Code # previously          Y           No
                      (spray, brush, etc), per oz
                                                                                   used is now liquid
                                                                                   ostomy skin barrier.
                      Adhesive remover wipes,                                      Ostomy skin bond
Ostomy Supplies                                          A4365        A4370                                   Y           No
                      any type, per 50                                             or cement remover
                      Adhesive remover or
                      solvent (for tape, cement,                                   Ostomy skin bond
Ostomy Supplies                                          A4455        A4370                                   Y           No
                      or other adhesive), per                                      or cement remover
                      ounce
                                                                                   Ileostomy set - use
                                                                                   A4550 - Surgical
                      Ostomy pouch, urinary with
                                                                                   Tray
Ostomy Supplies       faceplate attached, rubber,        A4380        A4380                                     Y          No
                                                                                    (Ileum - section of
                      each
                                                                                   small intestine - not
                                                                                   urinary)
                                                                                   Ileal bladder set -
                      Ostomy pouch, drainable,                                     This is not a
                      with extended wear barrier                                   current discription
Ostomy Supplies                                          A4390        A4390                                     Y          No
                      attached, with built-in                                      for this code -
                      convexity (1 piece), each                                    crossover not
                                                                                   available.
                                                                                   Irrigation set for
Ostomy Supplies       Ostomy irrigation set              A4400        A4400                                     Y          No
                                                                                   irrigation of ostomy
                      Ostomy lubricant, per                                        Ostomy lubricant,
Ostomy Supplies                                          A4402        A4402                                     Y          No
                      ounce                                                        per ounce           Effective March 1, 2004
                                                   Montana Medicaid
                                             Nursing Facility Code Crosswalk




                                                      CURRENT      PREVIOUS                            MEDICARE Prior
Category of Service        CURRENT ITEM                                            PREVIOUS
                                                     PROCEDURE     CODE OR                               EOB    Auth.
     Section #              DESCRIPTION                                           DESCRIPTION
                                                        CODE        CODES                               NEEDED Required
Ostomy Supplies       Ostomy rings, each               A4404         A4404      Ostomy rings, each         Y          No

                                                                                41) Not otherwise
                                                                                classified ostomy
                                                                                supplies
                                                                                A4440) Not
                      Ostomy supply;                                A4421 &
Ostomy Supplies                                        A4421                    otherwise classified       Y          No
                      miscellaneous                                  A4440
                                                                                ureterostomy
                                                                                supplies - this is a
                                                                                discontinued code -
                                                                                use A4421


                      Insertion tray without
                      drainage bag with
                      indwelling catheter, Foley
Ureterostomy
                      type, two-way latex with         A4311         A4430      Ureterostomy set           y          No
Supplies
                      coating (teflon, silicone,
                      silicone elastomer or
                      hydrophilic, etc.)
                      Insertion tray without
Ureterostomy          drainage bag with
                                                       A4312         A4430      Ureterostomy set           y          No
Supplies              indwelling catheter, Foley
                      type, two-way, all silicone
                      Insertion tray without
                      drainage bad with
Ureterostomy
                      indwelling catheter, Foley       A4313         A4430      Ureterostomy set           y          No
Supplies
                      type, three-way, for
                      continuous irrigation
                      Insertion tray with drainage
                      bag with indwelling
                      catheter, Foley type, two-
Ureterostomy
                      way latex with coating           A4314         A4430      Ureterostomy set           y          No
Supplies
                      (Teflon, silicone, silicone
                      elastomer or hydrophilic,
                      etc.)
                      Insertion tray with drainage
Ureterostomy          bag with indwelling
                                                       A4315         A4430      Ureterostomy set           y          No
Supplies              catheter, Foley type, two-
                      way, all silicone
                      Insertion tray with drainage
                      bag with indwelling
Ureterostomy
                      catheter, Foley type, three-     A4316         A4430      Ureterostomy set           y          No
Supplies
                      way, for continuous
                      irrigation
                      Insertion tray without
Ureterostomy
                      drainage bag and without         A4310         A4430      Ureterostomy set           y          No
Supplies
                      catheter (accessories only)
                                                                                Colon Tube - no
Ureterostomy                                                       W2540 (not
                                                     Delete Code                crossover code             Y          No
Supplies                                                             used)
                                                                                available


                                                                                                   Effective March 1, 2004
                                                    Montana Medicaid
                                              Nursing Facility Code Crosswalk

                                                      CURRENT      PREVIOUS                             MEDICARE Prior
Category of Service        CURRENT ITEM                                            PREVIOUS
                                                     PROCEDURE     CODE OR                                EOB    Auth.
     Section #              DESCRIPTION                                           DESCRIPTION
                                                        CODE        CODES                                NEEDED Required
                                                                                Disposable
                                                                                colostomy
                                                                                appliance/acc this
Ureterostomy                                                       W2542 (not
                                                     Delete Code                code was not used             Y          No
Supplies                                                             used)
                                                                                and is discontinued
                                                                                with no crossover
                                                                                code available.
                      Ostomy irrigation supply;
Ureterostomy                                                                    Colostomy
                      cone/catheter, including         A4399         W2544                                    Y          No
Supplies                                                                        irrigation appliance
                      brush
Ureterostomy          Ostomy irrigation supply;                                 Colostomy
                                                       A4398         W2545                                    Y          No
Supplies              bag, each                                                 irrigation accessory

Ureterostomy          Irrigation supply; sleeve,                                Colostomy
                                                       A4397         W2545                                    Y          No
Supplies              each                                                      irrigation accessory
                                                                                Colostomy
                                                                                appliance, non-
Ureterostomy
                                                     Delete Code     W2546      disposable                               No
Supplies
                                                                                no crossover code
                                                                                available
                                                                                Colostomy
Ureterostomy                                                                    appliance
                                                     Delete Code     W2547                                               No
Supplies                                                                        no crossover code
                                                                                available
                                                                                Disposable
                                                                                ileostomy
Ureterostomy
                                                     Delete Code     W2549      accessory                                No
Supplies
                                                                                no crossover code
                                                                                available
                                                                                Disposable
                                                                                urostomy bags -
Ureterostomy
                                                     Delete Code     W2563      see codes for                            No
Supplies
                                                                                ostomy pouch,
                                                                                urinary
Ureterostomy          Irrigation tray with bulb or
                                                       A4320         W2570      Piston irrigation set        N           No
Supplies              piston syringe, any purpose


                      Urine test or reagent strips                              Blood or Urine
Diagnostic Agents     or tablets (100 tablets or       A4250         A4253      control strips or            N           No
                      strips)                                                   tablets
                      Blood glucose test or
                                                                                Blood or Urine
                      reagent strips for home
Diagnostic Agents                                      A4253         A4253      control strips or            N           No
                      blood glucose monitor, per
                                                                                tablets
                      50
                      Blood glucose test strips,                                Dextrose or
Diagnostic Agents                                      A4772         A4772                                   N           No
                      for dialysis, per 50                                      glucose test strips

                      Implantable access
                                                                                Implantable,
                      catheter, (e.g., venous,
                                                                                vascular access
                      arterial, epidural
Vascular Catheters                                     A4300         A4300      portal/catheter                          No
                      subarachnoid, or
                                                                                (venous arterial or
                      peritoneal, etc.) external
                                                                                peritoneal)
                      access
                                                                                                      Effective March 1, 2004
                                                    Montana Medicaid
                                              Nursing Facility Code Crosswalk


                                                      CURRENT     PREVIOUS                             MEDICARE Prior
Category of Service        CURRENT ITEM                                            PREVIOUS
                                                     PROCEDURE    CODE OR                                EOB    Auth.
     Section #              DESCRIPTION                                           DESCRIPTION
                                                        CODE       CODES                                NEEDED Required

                                                                              Indwelling catheter,
                                                                              Foley type, two-
                                                                              way teflon:
                                                                              Indwelling catheter,
                                                                              Foley type, two-
                      Indwelling catheter; Foley
                                                                              way, latex:
                      type, two-way latex with                     A4341,
                                                                              Indwelling catheter,
Urinary Catheters     coating (Teflon, Silicone,       A4338       A4342,                                    Y          No
                                                                              Foley type, two-
                      Silicone elastomer, or                     A4343, A4345
                                                                              way, latex with
                      hydrophilic, etc.), each
                                                                              teflon coating;
                                                                              Indwelling catheter,
                                                                              Foley type, two-
                                                                              way, silicone with
                                                                              elastomer coating.


                      Indwelling catheter; Foley                                Indwelling catheter;
Urinary Catheters     type, two-way all silicone,      A4344        A4344       Foley type, two-             Y          No
                      each                                                      way all silicone

                                                                                Indwelling catheter,
                      Indwelling catheter; Foley                                Foley type, three-
Urinary Catheters     type, three-way for              A4346        A4346       way, latex or teflon         Y          No
                      continuous irrigation, each                               for continuous
                                                                                irrigation
                      Male external catheter with
                      or without adhesive, with                                 External catheter,
Urinary Catheters                                      A4347        A4347                                   N           No
                      or without anti-reflux                                    condom type
                      devise; per dozen
                      Male external catheter with
                                                                                Urinary collection
                      integral collection
                                                                                and retention
Urinary Catheters     compartment, extended            A4348        A4348                                   N           No
                                                                                system, drainage
                      wear, each (e.g., 2 per
                                                                                bag with tube
                      month)
                                                                              Catheter care kit;
                      Incontinence supply,
Urinary Catheters                                      A4335     A4350, W2559 Catheter misc.                 Y          No
                      miscellaneous
                                                                              supplies
                                                                              Catheter insertion
                      Insertion tray with drainage
Urinary Catheters                                      A4354        A4354     tray, without tube            N           No
                      bag but without catheter
                                                                              and drainage bag.
                      Irrigation tubing set for
                      continuous bladder
                                                                                3-way irrigation set
Urinary Catheters     irrigation through a tree-       A4355        A4355                                    Y          No
                                                                                for catheter
                      way indwelling Foley
                      catheter, each
                      Intermittent urinary
                      catheter; straight tip, with
                      or without coating (Teflon,
Urinary Catheters                                      A4351        W2558       Urethral catheter           N           No
                      silicone, silicone
                      elastomer, or hydrophilic,
                      etc.), each
                      Intermittent urinary
                                                                                Urethral catheter
Urinary Catheters     catheter, with insertion         A4353        W2562                                   N           No
                                                                                with tray
                      supplies
                                                                                                     Effective March 1, 2004
                                                     Montana Medicaid
                                               Nursing Facility Code Crosswalk


                                                      CURRENT     PREVIOUS                               MEDICARE Prior
Category of Service        CURRENT ITEM                                              PREVIOUS
                                                     PROCEDURE    CODE OR                                  EOB    Auth.
     Section #              DESCRIPTION                                             DESCRIPTION
                                                        CODE       CODES                                  NEEDED Required
                      Intermittent urinary
                      catheter; coude (curved)
                      tip, with or without coating
Urinary Catheters                                      A4352        W2564         Caudi-tip catheter          N           No
                      (Teflon, silicone, silicone
                      elastomeric or hydrophilic,
                      etc.), each
                      Male external catheter,                                     Male mentor
Urinary Catheters                                      A4324        W2565                                      Y          No
                      with adhesive coating, each                                 catheter
                      Male external catheter
                      specialty type (e.g.                                        Male mentor
Urinary Catheters                                      A4326        W2565                                      y          No
                      inflatable, faceplate, etc.)                                catheter
                      each
                      Male external catheter,                                     Male mentor
Urinary Catheters                                      A4325        W2565                                      y          No
                      with adhesive strip, each                                   catheter

                                                                              Urinary collection
                      Urinary drainage bag, leg
                                                                              and retention
External Urinary      or abdomen, vinyl, with or
                                                       A4358     A4349. A4358 system, leg bag                 N           No
Supplies              without tube, with straps,
                                                                              with tube; Urinary
                      each
                                                                              leg bag
                      External urethral clamp or
External Urinary      compression device (not to
                                                       A4356         A4356        Incontinence Clamp          N           No
Supplies              be used for a catheter
                      clamp), each
                      Bedside drainage bag, day
External Urinary      or night, with or without                                   Urinary drainage
                                                       A4357         A4357                                    N           No
Supplies              anti-reflux device, with or                                 bag
                      without tube, each
External Urinary      Urinary suspensory without                 Not previously
                                                       A4359                                                              No
Supplies              leg bag, each                                 included


                    Tracheostomy care kit for                                     Tracheostomy care
Tracheal Appliances                                    A4629        W2802                                     N           No
                    established tracheostomy                                      kit
                    Oropharyngeal suction                                         Nasopharyngeal/tra
Tracheal Appliances                                    A4628        W2803                                     N           No
                    catheter, each                                                cheal suction kit


                      Portable oxygen contents,
                      gaseous (for use only with
                                                                                  Oxygen contents,
                      portable gaseous systems
Oxygen                                                 E0443         E0400        gaseous, per cubic          N           No
                      when no stationary gas or
                                                                                  foot
                      liquid system is used), one
                      month's supply = 1 unit


                      Oxygen contents, gaseous
                      (for use with owned
                      gaseous stationary system                                   Oxygen contents,
Oxygen                or when both a stationary        E0441         E0405        gaseous, per 100            N           No
                      and portable liquid system                                  cubic feet
                      are owned), one month's
                      supply=1 unit

                                                                                                       Effective March 1, 2004
                                                   Montana Medicaid
                                             Nursing Facility Code Crosswalk

                                                     CURRENT      PREVIOUS                           MEDICARE Prior
Category of Service        CURRENT ITEM                                           PREVIOUS
                                                    PROCEDURE     CODE OR                              EOB    Auth.
     Section #              DESCRIPTION                                          DESCRIPTION
                                                       CODE        CODES                              NEEDED Required
                      Portable oxygen contents,
                      liquid (for use only with
                      portable liquid systems                                  Oxygen contents,
Oxygen                                                E0444        E0410                                 N           No
                      when no stationary gas or                                liquid per pound
                      liquid system is used), one
                      month's supply = 1 unit
                      Oxygen contents, liquid
                      (for use with owned liquid
                      stationary system or when                                Oxygen contents,
Oxygen                both a stationary and           E0442        E0415       liquid, per 100           N           No
                      portable liquid system are                               pounds
                      owned), one month's
                      supply= 1 unit
                      Oxygen contents - either
                                                                               Oxygen contents,
Oxygen                gas or liquid and either      E0441-E0444    W2622                                 N           No
                                                                               Linde reservoir
                      portable or stationary
                      Oxygen contents - either
                                                                               Oxygen contents,
Oxygen                gas or liquid and either      E0441-E0444    W2623                                 N           No
                                                                               Liberator
                      portable or stationary
                      Oxygen contents - either
                                                                               Oxygen contents,
Oxygen                gas or liquid and either      E0441-E0444    W2624                                 N           No
                                                                               LV 160
                      portable or stationary
                      Oxygen contents - either
                                                                               Oxygen contents,
Oxygen                gas or liquid and either      E0441-E0444    W2625                                 N           No
                                                                               PCU reservoir
                      portable or stationary
                      Oxygen contents - either
                                                                               Oxygen contents,
Oxygen                gas or liquid and either      E0441-E0444    W2626                                 N           No
                                                                               GP-45
                      portable or stationary
                      Oxygen contents - either
                                                                               Oxygen contents,
Oxygen                gas or liquid and either      E0441-E0444    W2627                                 N           No
                                                                               D cylinder
                      portable or stationary
                      Oxygen contents - either
                                                                               Oxygen contents, E
Oxygen                gas or liquid and either      E0441-E0444    W2628                                 N           No
                                                                               cylinder
                      portable or stationary
                      Oxygen contents - either
                                                                               Oxygen cylinder
Oxygen                gas or liquid and either      E0441-E0444    W2629                                 N           No
                                                                               contents, GDL-K
                      portable or stationary
                      Oxygen contents - either
                      gas or liquid - stationary
Oxygen                                              E0441-E0442    W2774       Piped in oxygen           N           No
                      One month's supply = 1
                      unit

Oxygen & Related
                      Cannula, nasal                  A4615        E1351       Cannula                   N           No
Respiratory Equip
Oxygen &
                      Tracheostomy, inner
Respiratory                                           A4623        E1351       Cannula                   N           No
                      cannula (replacement only)
Equipment
Oxygen &
                                                                               Tubing, unspecified
Respiratory           Tubing (oxygen), per foot       A4616        E1352                                 N           No
                                                                               length, per foot
Equipment
Oxygen &
Respiratory           Regulator                       E1353        E1353       Regulator                 N           No
Equipment
Oxygen &
Respiratory           Mouthpiece                      A4617        E1354       Mouth Piece                 N          No
Equipment                                                                                         Effective March 1, 2004
                                                     Montana Medicaid
                                               Nursing Facility Code Crosswalk


                                                     CURRENT      PREVIOUS                              MEDICARE Prior
Category of Service        CURRENT ITEM                                             PREVIOUS
                                                    PROCEDURE     CODE OR                                 EOB    Auth.
     Section #              DESCRIPTION                                            DESCRIPTION
                                                       CODE        CODES                                 NEEDED Required
Oxygen &
Respiratory           Stand / rack                     E1355        E1355        Stand / rack                N           No
Equipment
Oxygen &
Respiratory           Face Tent                        A4619        E1371        Face Tent                   N           No
Equipment
Oxygen &
                                                                  W2637 (not
Respiratory                                         Delete Code                  IPPB kit                    N           No
                                                                    used)
Equipment
Oxygen &              Respiratory suction pump,
Respiratory           home model, portable or          E0600        W2638        Portable aspirator          N           No
Equipment             stationary, electric
Oxygen &
Respiratory           Breathing circuits               A4618        W2639        Connectors                  N           No
Equipment
                      Full face mask used with
                      positive airway pressure
                      device
Oxygen &
Respiratory                                            A7030        W2640        Face Mask                   N           No
                      (A7031 Replacement
Equipment
                      facemask interface,
                      replacement for full
                      facemask, each)
Oxygen &              Replacement facemask
Respiratory           interface, replacement for       A7031        W2640        Face Mask                   N           No
Equipment             full facemask, each
Oxygen &
                      Variable concentration
Respiratory                                            A4620        W2640        Face Mask                   N           No
                      mask
Equipment
Oxygen &
                      Implanted pleural catheter,
Respiratory                                            A7042        W2642        Nasal Catheter              N           No
                      each
Equipment
Oxygen &
                      Tubing used with positive                                  Disposable IPPB
Respiratory                                            A7037        W2643                                    N           No
                      airway pressure devise                                     tubing
Equipment
                      Humidifier, durable for
Oxygen &              supplemental
                                                                                 Disposable
Respiratory           humidification during IPPB       E0560        W2644                                    N           No
                                                                                 humidifiers
Equipment             treatment or oxygen
                      delivery
Oxygen &              Corrugated tubing, non-
Respiratory           disposable, used with large      A7011        W2645        Extension hoses                         No
Equipment             volume nebulizer, 10 ft.

Oxygen &              Corrugated tubing,
Respiratory           disposable, used with large      A7010        W2645        Extension hoses                         No
Equipment             volume nebulizer, 100 ft.
                      Nebulizer, with compressor
Oxygen &              (index lists "Madamist II                                  MADA plastic
Respiratory           medication                       E0570        W2646        nebulizer with              N           No
Equipment             compressor/nebulizer as                                    mask and tube
                      E0570")
                                                                                                      Effective March 1, 2004
                                                     Montana Medicaid
                                               Nursing Facility Code Crosswalk


                                                      CURRENT      PREVIOUS                               MEDICARE Prior
Category of Service         CURRENT ITEM                                            PREVIOUS
                                                     PROCEDURE     CODE OR                                  EOB    Auth.
     Section #               DESCRIPTION                                           DESCRIPTION
                                                        CODE        CODES                                  NEEDED Required
                       Nasal interface (mask or
Oxygen &               cannula type) used with
Respiratory            positive airway pressure        A7034        W2647        Nasal Oxygen kit            N          No
Equipment              device, with or without
                       head strap
Oxygen &                                                                         Oxygen cart for
Respiratory                                          Delete Code    W2653        portable tank               N          No
Equipment                                                                        (purchase)
                       Portable gaseous oxygen
                       system, rental; includes
Oxygen &
                       portable container,                                       Cylinder rental, one
Respiratory                                            E0431        W2712                                    Y          No
                       regulator, flowmeter,                                     month
Equipment
                       humidifier, cannula or
                       mask, and tubing.
                       Portable liquid oxygen
                       system rental; includes
Oxygen &               portable container, supply
                                                                                 Cylinder rental, one
Respiratory            reservoir, humidifier,          E0434        W2712                                    y          No
                                                                                 month
Equipment              flowmeter, refill adaptor,
                       contents gauge, cannula or
                       mask, and tubing


Enteral & Parenteral   Enteral feeding supply kit;
                                                       B4034        B4034        monthly                     Y          Yes
Supplies               syringe, per day
Enteral & Parenteral   Enteral feeding supply kit;
                                                       B4035        B4035        monthly                     Y          Yes
Supplies               pump fed, per day
Enteral & Parenteral   Enteral feeding supply kit;
                                                       B4036        B4036        monthly                     Y          Yes
Supplies               gravity fed, per day
                                                                                 Nasal gastric
                                                                                 tubing with thin
Enteral & Parenteral   Nasogastric tubing with                     B4081 or      wire or cotton (e.g.
                                                       B4081                                                 Y          No
Supplies               stylet                                       B4161        Travasorb,
                                                                                 Entriflex, Dobb
                                                                                 Huff, Flexiflow, etc.)

Enteral & Parenteral   Nasogastric tubing without                  B4082 or      Nasogastric tubing
                                                       B4082                                                 Y          No
Supplies               stylet                                       B4161        without stylet
Enteral & Parenteral                                                             Stomach tube -
                       Stomach tube - Levine type      B4083        B4083                                    Y          No
Supplies                                                                         Levine type
                       Gastrostomy/jejunostomy
Enteral & Parenteral   tube, any material, any                                   Gastrostomy/Jejuno
                                                       B4086        B4084                                    Y          No
Supplies               type, (standard or low                                    stomy tubing
                       profile), each
                                                                                 Parenteral nutrition
Enteral & Parenteral   Parenteral nutrition supply
                                                       B4220        B4220        supply kit for one          Y          No
Supplies               kit; premix, per day
                                                                                 month Premix

                                                                                 Parenteral nutrition
Enteral & Parenteral   Parenteral nutrition
                                                       B4222        B4222        supply kit for one          Y          No
Supplies               administration kit, per day
                                                                                 month Homemix
Enteral & Parenteral   Parenteral nutrition
                                                       B4224        B4224        per month                   Y          No
Supplies               administration kit, per day
                                                                                                     Effective March 1, 2004
                                                       Montana Medicaid
                                                 Nursing Facility Code Crosswalk



                                                      CURRENT       PREVIOUS                               MEDICARE Prior
Category of Service         CURRENT ITEM                                              PREVIOUS
                                                     PROCEDURE      CODE OR                                  EOB    Auth.
     Section #               DESCRIPTION                                             DESCRIPTION
                                                        CODE         CODES                                  NEEDED Required
                                                                                   Enteral supplies
Enteral & Parenteral
                       NOC for enteral supplies          B9998        B9998        not elsewhere                 Y          No
Supplies
                                                                                   classified
                                                                                   Parenteral supplies
Enteral & Parenteral   NOC for parenteral
                                                         B9999        B9999        not elsewhere                 Y          No
Supplies               supplies
                                                                                   classified
Enteral & Parenteral   Syringe sterile 20cc or
                                                         A4213        W2500        Feeding syringe               Y          No
Supplies               greater, each
Enteral & Parenteral
                                                      Delete Code     W2569        Gavage feeding set            Y          No
Supplies
Enteral & Parenteral   Enteral feeding supply kit;
                                                         B4036        W2796        Enteric feeding set           Y          No
Supplies               gravity fed, per day
Enteral & Parenteral   Enteral feeding supply kit;
                                                         B4035        W2796        Enteric feeding set           Y          No
Supplies               pump fed, per day
Enteral & Parenteral   Enteral feeding supply kit;
                                                         B4034        W2796        Enteric feeding set           Y          No
Supplies               syringe, per day
Enteral & Parenteral   NOC Enteral & NOC                B9998 or
                                                                      W2798        Nutrition container           Y          No
Supplies               Parenteral                        B9999
                       Implantable access
                       catheter, (e.g., venous,
Enteral & Parenteral   arterial, epidural
                                                         A4300        W2799        IV intercath                  Y          No
Supplies               subarachnoid, or
                       peritoneal, etc.) external
                       access
Enteral & Parenteral   Blood tubing, arterial or                    W2800 or       IV tubing or IV
                                                         A4750                                                   Y          No
Supplies               venous, each                                  W2801         piggyback tubing

                                                                                   Enteral formulae;
                                                                                   Category I: Intact
                                                                                   Protein/ Protein
                                                                                   Isolates (e.g.,
                                                                                   Enrich, Ensure,
                     Enteral formulae; category
                                                                                   Ensure powder,
                     I: semi-synthetic intact
                                                                                   Isocal, Lonalac
Enteral & Parenteral protein/protein isolates,
                                                         B4150        B4150        powder, Meritene,             Y          Yes
Formulas & Solutions administered through an
                                                                                   Meritene powder,
                     enteral feeding tube, 100
                                                                                   Osmolite, Portagen
                     calories = 1 unit
                                                                                   powder, Sustacal,
                                                                                   Renu, Sustagen
                                                                                   powder, Travasorb)
                                                                                   100 calories = 1
                                                                                   unit
                                                                                   Enteral formulae;
                                                                                   Category I -
                     Enteral formulae; category
                                                                                   Natural intact
                     I: natural intact
                                                                                   Protein/Protein
Enteral & Parenteral protein/protein isolates,
                                                         B4151        B4151        Isolates, (e.g.,              Y          Yes
Formulas & Solutions administered through an
                                                                                   Complete B,
                     enteral feeding tube, 100
                                                                                   Vitaneed, Compete
                     calories = 1 unit
                                                                                   B Modified) 100
                                                                                   calories = 1 unit


                                                                                                         Effective March 1, 2004
                                                   Montana Medicaid
                                             Nursing Facility Code Crosswalk




                                                      CURRENT    PREVIOUS                              MEDICARE Prior
Category of Service        CURRENT ITEM                                           PREVIOUS
                                                     PROCEDURE   CODE OR                                 EOB    Auth.
     Section #              DESCRIPTION                                          DESCRIPTION
                                                        CODE      CODES                                 NEEDED Required
                                                                               Enteral formulae;
                                                                               Category II: Intact
                                                                               Protein/Protein
                     Enteral formulae; category
                                                                               Isolates (calorically
                     II: intact protein / protein
                                                                               dense), (e.g.,
Enteral & Parenteral isolates (calorically dense),
                                                       B4152      B4152        Magnacal, Isocal            Y          Yes
Formulas & Solutions administered through an
                                                                               HCN, Sustacal HC,
                     enteral feeding tube, 100
                                                                               Ensure Plus,
                     calories = 1 unit
                                                                               Ensure Plus HN)
                                                                               100 calories = 1
                                                                               unit
                                                                               Enteral formulae;
                                                                               Category III:
                                                                               Hydrolyzed
                                                                               Protein/Amino
                                                                               Acids (e.g.,
                                                                               Critcare HN,
                     Enteral formulae; category
                                                                               Ensure HN,
                     III: hydrolyzed
                                                                               Vivonex T.E.N.
Enteral & Parenteral protein/amino acids,
                                                       B4153      B4153        (total enteral              Y          Yes
Formulas & Solutions administered through an
                                                                               nutrition), Vivonex
                     enteral feeding tube, 100
                                                                               HN, Vital (Vital
                     calories = 1 unit
                                                                               HN), Travasorb
                                                                               HN, Isotein
                                                                               Osmolite HN,
                                                                               Precision HN,
                                                                               Precision Isotonic)
                                                                               100 calories = 1 un
                                                                               Enteral formulae;
                                                                               Category !V:
                                                                               Defined Formula
                                                                               for Special
                     Enteral formulae; category
                                                                               Metabolic Need
                     !V: defined formula for
                                                                               (e.g., Hepatic-Acid,
Enteral & Parenteral special metabolic need,
                                                       B4154      B4154        Travasorb Hepatic,          Y          Yes
Formulas & Solutions administered through an
                                                                               Travasorb MCT,
                     enteral feeding tube, 100
                                                                               Travasorb Renal,
                     calories = 1 unit
                                                                               Traum-Aid,
                                                                               Tramacal, Aminaid)
                                                                               100 calories = 1
                                                                               unit




                                                                                                   Effective March 1, 2004
                                                  Montana Medicaid
                                            Nursing Facility Code Crosswalk


                                                    CURRENT    PREVIOUS                              MEDICARE Prior
Category of Service        CURRENT ITEM                                          PREVIOUS
                                                   PROCEDURE   CODE OR                                 EOB    Auth.
     Section #              DESCRIPTION                                         DESCRIPTION
                                                      CODE      CODES                                 NEEDED Required
                                                                              Enteral formulae;
                                                                              Category V:
                                                                              Modular
                                                                              Components
                                                                              (protein,
                                                                              carbohydrates, fat)
                                                                              e.g., Propac,
                     Enteral formulae; category
                                                                              Gerval Protein,
                     V: modular components,
Enteral & Parenteral                                                          Promix, Casec,
                     administered through an         B4155       B4155                                     Y          Yes
Formulas & Solutions                                                          Moducal,
                     enteral feeding tube, 100
                                                                              Controlyte,
                     calories = 1 unit
                                                                              Polycose Liquid or
                                                                              Powder, Travasorb
                                                                              MCT, Sumacal,
                                                                              Microlipids, MCT
                                                                              Oil, Nutri-Source)
                                                                              100 calories = 1
                                                                              unit
                                                                              Enteral formulae;
                                                                              Category VI:
                     Enteral formulae; category
                                                                              standardized
                     VI: standardized nutrients,
Enteral & Parenteral                                                          Nutrients (Vivonex
                     administered through an         B4156       B4156                                     Y          Yes
Formulas & Solutions                                                          STD, Travasorb
                     enteral feeding tube, 100
                                                                              STD, and Precision
                     calories = 1 unit
                                                                              LR) 100 calories =
                                                                              1 unit
                     Parenteral nutrition
                     solution: carbohydrates                                  50% Dextrose
Enteral & Parenteral
                     (dextrose), 50% or less         B4164       B4164        solution (500 ml =           Y          Yes
Formulas & Solutions
                     (500 ml = 1 unit) - home                                 1 unit)
                     mix
                     Parenteral nutrition                                     Parenteral nutrition
Enteral & Parenteral solution; amino acid, 3.5%,                              solution; amino
                                                     B4168       B4168                                     Y          Yes
Formulas & Solutions (500 ml = 1 unit) - home                                 acid, 3.5%, (500 ml
                     mix                                                      = 1 unit) - home mix

                                                                              Parenteral nutrition
                     Parenteral nutrition
                                                                              solution; amino
Enteral & Parenteral solution; amino acid, 5.5%
                                                     B4172       B4172        acid, 5.5% through           Y          Yes
Formulas & Solutions through 7% (500 ml = 1
                                                                              7% (500 ml = 1 unit
                     unit - home mix
                                                                              - home mix

                                                                              Parenteral nutrition
                     Parenteral nutrition
                                                                              solution; Amino
Enteral & Parenteral solution; amino acid, 7%
                                                     B4176       B4176        Acid greater than            Y          Yes
Formulas & Solutions through 8.5% (500 ml = 1
                                                                              7% (500 ml = 1
                     unit) - home mix
                                                                              unit) - Homemix

                                                                              Parenteral nutrition
                     Parenteral nutrition
                                                                              solution; amino
Enteral & Parenteral solution; amino acid,
                                                     B4178       B4178        acid, greater than           Y          Yes
Formulas & Solutions greater than 8.5% (500 ml
                                                                              8.5% (500 ml = 1
                     = 1 unit) home mix
                                                                              unit) home mix

                                                                                                   Effective March 1, 2004
                                                  Montana Medicaid
                                            Nursing Facility Code Crosswalk


                                                    CURRENT    PREVIOUS                              MEDICARE Prior
Category of Service        CURRENT ITEM                                          PREVIOUS
                                                   PROCEDURE   CODE OR                                 EOB    Auth.
     Section #              DESCRIPTION                                         DESCRIPTION
                                                      CODE      CODES                                 NEEDED Required
                                                                              Parenteral nutrition
                     Parenteral nutrition
                                                                              solution;
                     solution; carbohydrates
Enteral & Parenteral                                                          carbohydrates,
                     (dextrose), greater than        B4180       B4180                                   Y          Yes
Formulas & Solutions                                                          greater than 50%
                     50% (500 ml = 1 unit)
                                                                              (500 ml = 1 unit)
                     home mix
                                                                              home mix
                                                                              Parenteral Nutrition
                     Parenteral Nutrition
                                                                              solution; lipids,
Enteral & Parenteral solution; lipids, 10% with
                                                     B4184       B4184        10% with                   Y          Yes
Formulas & Solutions administration set (500 ml
                                                                              administration set
                     = 1 unit)
                                                                              (500 ml = 1 unit)
                                                                              Parenteral nutrition
                     Parenteral nutrition
                                                                              solution; lipids,
Enteral & Parenteral solution; lipids, 20% with
                                                     B4186       B4186        20% with                   Y          Yes
Formulas & Solutions administration set (500 ml
                                                                              administration set
                     = 1 unit)
                                                                              (500 ml = 1 unit)
                                                                              Parenteral nutrition
                                                                              solution;
                     Parenteral nutrition
                                                                              compounded
                     solution; compounded
                                                                              amino acid and
                     amino acid and
                                                                              carbohydrates with
                     carbohydrates with
Enteral & Parenteral                                                          electrolytes, trace
                     electrolytes, trace             B4189       B4189                                   Y          Yes
Formulas & Solutions                                                          elements, and
                     elements, and vitamins,
                                                                              vitamins, including
                     including preparation, any
                                                                              preparation, any
                     strength, 10 to 51 grams of
                                                                              strength, 10 to 51
                     protein - premix
                                                                              grams of protein -
                                                                              premix

                                                                              Parenteral nutrition
                                                                              solution;
                     Parenteral nutrition
                                                                              compounded
                     solution; compounded
                                                                              amino acid and
                     amino acid and
                                                                              carbohydrates with
                     carbohydrates with
Enteral & Parenteral                                                          electrolytes, trace
                     electrolytes, trace             B4193       B4193                                   Y          Yes
Formulas & Solutions                                                          elements, and
                     elements, and vitamins,
                                                                              vitamins, including
                     including preparation, any
                                                                              preparation, any
                     strength, 52 to 73 grams of
                                                                              strength, 52 to 73
                     protein - premix
                                                                              grams of protein -
                                                                              premix

                                                                              Parenteral nutrition
                                                                              solution;
                     Parenteral nutrition
                                                                              compounded
                     solution; compounded
                                                                              amino acid and
                     amino acid and
                                                                              carbohydrates with
                     carbohydrates with
Enteral & Parenteral                                                          electrolytes, trace
                     electrolytes, trace             B4197       B4197                                   Y          Yes
Formulas & Solutions                                                          elements, and
                     elements, and vitamins,
                                                                              vitamins, including
                     including preparation, any
                                                                              preparation, any
                     strength, 74 to 100 grams
                                                                              strength, 74 to 100
                     of protein - premix
                                                                              grams of protein -
                                                                              premix
                                                                                                 Effective March 1, 2004
                                                   Montana Medicaid
                                             Nursing Facility Code Crosswalk




                                                   CURRENT      PREVIOUS                              MEDICARE Prior
Category of Service        CURRENT ITEM                                           PREVIOUS
                                                  PROCEDURE     CODE OR                                 EOB    Auth.
     Section #              DESCRIPTION                                          DESCRIPTION
                                                     CODE        CODES                                 NEEDED Required
                                                                               Parenteral nutrition
                                                                               solution;
                     Parenteral nutrition
                                                                               compounded
                     solution; compounded
                                                                               amino acid and
                     amino acid and
                                                                               carbohydrates with
                     carbohydrates with
Enteral & Parenteral                                                           electrolytes, trace
                     electrolytes, trace             B4199        B4199                                   Y          Yes
Formulas & Solutions                                                           elements, and
                     elements, and vitamins,
                                                                               vitamins, including
                     including preparation, any
                                                                               preparation, any
                     strength, over 100 grams
                                                                               strength, over 100
                     of protein - premix
                                                                               grams of protein -
                                                                               premix

                                                                               Parenteral
                     Parenteral nutrition;
                                                                               nutrition; Additives
                     additives (vitamins, trace
Enteral & Parenteral                                                           (vitamins, trace
                     elements, heparin,              B4216        B4216                                   Y          Yes
Formulas & Solutions                                                           elements, Heparin,
                     electrolytes) - home mix,
                                                                               electrolytes) -
                     per day
                                                                               Homemix - per day

                                                                               Parenteral nutrition
                                                                               solution;
                     Parenteral nutrition
                                                                               compounded
                     solution; compounded
                                                                               amino acid and
                     amino acid and
                                                                               carbohydrates with
                     carbohydrates with
                                                                               electrolytes, trace
Enteral & Parenteral electrolytes, trace
                                                     B5000        B5000        elements, and              Y          Yes
Formulas & Solutions elements, and vitamins,
                                                                               vitamins, including
                     including preparation, any
                                                                               preparation, any
                     strength, renal-amirosyn
                                                                               strength, renal-
                     RF, nephramine, renamine
                                                                               amirosyn RF,
                     - premix
                                                                               nephramine,
                                                                               renamine - premix

                                                                               Parenteral nutrition
                                                                               solution;
                     Parenteral nutrition                                      compounded
                     solution; compounded                                      amino acid and
                     amino acid and                                            carbohydrates with
                     carbohydrates with                                        electrolytes, trace
Enteral & Parenteral
                     electrolytes, trace             B5100        B5100        elements, and              Y          Yes
Formulas & Solutions
                     elements, and vitamins,                                   vitamins, including
                     including preparation, any                                preparation, any
                     strength, stress - branch                                 strength, stress -
                     chain amino acids - premix                                branch chain
                                                                               amino acids -
                                                                               premix




                                                                                                  Effective March 1, 2004
                                                   Montana Medicaid
                                             Nursing Facility Code Crosswalk




                                                     CURRENT    PREVIOUS                              MEDICARE Prior
Category of Service        CURRENT ITEM                                           PREVIOUS
                                                    PROCEDURE   CODE OR                                 EOB    Auth.
     Section #              DESCRIPTION                                          DESCRIPTION
                                                       CODE      CODES                                 NEEDED Required
                                                                               Parenteral nutrition
                                                                               solution;
                     Parenteral nutrition
                                                                               compounded
                     solution; compounded
                                                                               amino acid and
                     amino acid and
                                                                               carbohydrates with
                     carbohydrates with
                                                                               electrolytes, trace
Enteral & Parenteral electrolytes, trace
                                                      B5200       B5200        elements, and              Y          Yes
Formulas & Solutions elements, and vitamins,
                                                                               vitamins, including
                     including preparation, any
                                                                               preparation, any
                     strength, hepatic -
                                                                               strength, hepatic -
                     freamine HBC,
                                                                               freamine HBC,
                     hepatamine - premix
                                                                               hepatamine -
                                                                               premix


                      Vent assist & management
Misc.- Prior          subsequent days                                          Nursing Hours add
Authorization            PRIOR                        94656       ?Z0766       on for vent patient        n          Yes
Required              AUTHORIZATION                                            services
                      REQUIRED
                      Miscellaneous DME
                      supply, accessory, and / or
                                                                               Prior Authorization
Misc.- Prior          service component of
                                                                               of supplies in
Authorization         another HCPCS code              A9900       Z0766                                   n          Yes
                                                                               extraordinary
Required
                                                                               amounts
                      PRIOR AUTHORIZATION
                      REQUIRED
                      Oxygen concentrator,
                      capable of delivering 85%
                      or greater oxygen
Misc.- Prior                                                                   Oxygen
                      concentration at the
Authorization                                         E1390       Z0766        concentrator PA            n          Yes
                      prescribed flow rate
Required                                                                       number
                      PRIOR AUTHORIZATION
                      REQUIRED




                                                                                                  Effective March 1, 2004

				
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